Provider Demographics
NPI:1164838025
Name:WEISS, NICOLE ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:WEISS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 27TH ST
Mailing Address - Street 2:APT 2F
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-2604
Mailing Address - Country:US
Mailing Address - Phone:203-444-5334
Mailing Address - Fax:
Practice Address - Street 1:3715 27TH ST
Practice Address - Street 2:APT 2F
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-2604
Practice Address - Country:US
Practice Address - Phone:203-444-5334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018833225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist